Whole Food Supplements: Is Juice Plus Good For You?

First, we want to make it clear that we have no ulterior motives when it comes to supplements. All we care about is doing what is best for patients based on the evidence we have. In fact, our view is not only unpopular but makes us less money (selling supplements is quite lucrative for people) so, unlike other sides of the argument, financial bias influencing our stance is not something our patients need to be concerned about. Moreover, we don’t have any vested interest in whether patients take supplements or not; however, as true patient advocates we do have a vested interest in our patients being well informed. Once truly well informed, then they can decide what works best for them, which may very well be different than what works best for us. Unfortunately, patients often don’t understand all the data and as such rely on other people to help them make their decision. It is very important however, that patients demand thorough exploration of all perspectives of a case prior to agreeing or disagreeing with anyone, especially by people in positions of influence. Unfortunately, we have found that in people’s desire to get healthy they often are quick to add things, like supplements, even after just a hint of good news usually as a result of just hearing part of the story. We see it as our job to add the missing perspective so that people can see everything a little more clearly and then make a truly well-informed decision.

Our biggest struggle as physicians is that almost all of our patient’s think that they are lacking something (or many things) and just need to find that key MISSING ingredient to achieve optimum health. Today I am going to talk about Juice Plus (JP) because this has seemed to receive quite a bit of attention as a possible key ingredient to improving the health of patients around the world. Unfortunately, supporters of JP have not provided a full perspective and as a result misled (possibly even unintentionally) many consumers. As a result it is impossible for consumers to make a truly well informed decision. We are going to use JP as an example of how all supplements and other quick-fix promises of improved health should be approached.

Currently, there is a small group of people who condemn supplements (such as vitamin A and iron) because they are “isolated nutrients.” They do so because there are studies that show that these isolated nutrients can be harmful and as such it makes sense to recommend against their consumption. However, JP is advertised as a “whole food” supplement and because of that is considered a healthier alternative to those potentially dangerous isolated nutrient supplements. Now, we agree, if truly a whole food, then yes, it would be a healthier supplement. But we have three major questions, one, is JP truly a whole food supplement? Two, even if it is a whole food supplement, how do we know we need it if we are already eating whole foods? And three, even if we prove that adding JP improves certain outcomes, are we sure that taking it won’t hurt us in any way? It is important to note from the start that we cannot tell you JP is bad as studies have not been done yet to show that (to do that we need at the very least, 10 year studies in large groups of people). But that doesn’t mean JP is safe either, rather that means it hasn’t been evaluated properly and as a result we just don’t know. And if you couldn’t tell yet, let’s make it clear that based on the limited data we have at this time we do have concerns with JP.

First of all, it is clear that JP is not a whole food supplement at least as we would define whole foods. A whole food supplement of fruits and vegetables (what JP says it is) would be apples and spinach jammed into a capsule. Now clearly you can’t jam a whole apple into a capsule so something has to be manipulated in some way. Even if you remove the water and were left with a dehydrated apple or a dehydrated kale chip you would have a better argument be called a whole food compared to taking the water/juice and throwing away everything else. Now, processing isn’t always unhealthy, such as processing apples into dried apple slices. Although eating a lot of dried fruits may lead to weight gain and for that reason may actually be unhealthy, especially if overconsumed. So when do we process foods you might ask? Likely one of two occasions: first, to change the texture or taste of the food (dehydrating corn into a corn chip or corn cake) and second, to be able to turn something into a substance that can be placed in capsule and sold to people as a way of improving their health (Juice Plus). Since fruits and vegetables have so much fiber that poses a major obstacle to getting a whole food into a capsule. As a result, JP proceeded with a two-step processing of the whole fruits and vegetables they used. First they extracted the juice from these fruits and vegetables eliminating a lot of the bulk from the fiber. Second, they dehydrated the juice into a powder/extract. However, when you extract the juice from a whole food, studies show that you lose as much as 90% of the nutrients with the waste (Journal of food science. Vol. 70, 2005. pp. S167-S171). In fact, much of the “waste” left behind after juicing has actually been shown to promote health and even decrease cancer risk (Food and Chemical Toxicology 45 (2007) 1224–1230). Interestingly, in a huge study looking at the different antioxidant levels of different foods, they showed that whole apples had 5343 umol TE/g per cup (a measure of antioxidant levels) and apple juice had only 975 umol TE/g per cup. That is 5.5 times (550%) more antioxidants in the whole apple compared to the juice! Even the dried apple slices had antioxidant levels many times more than the juice (Oxygen Radical Absorbance Capacity (ORAC) of Selected Foods – 2007, Nutrient Data Laboratory, U.S. Department of Agriculture (USDA) 2007). So clearly relying on the juice results in a loss of a significant portion of the health promoting factors found in the whole fruit and vegetable.

Worse yet, certain toxins get concentrated in juices that are not an issue when consuming whole fruits. For example, the mycotoxin patulin is responsible for causing the brown spots in apples and is potentially carcinogenic, but can be cut away and easily avoided when eating a whole fruit. However, companies that make juice can use apples that not only have these brown spots but can be downright rotten from this toxin, which causes concern as being a source of increased exposure to these toxins. In one study researchers analyzed different apple juices in countries around the world and found that patulin levels in 66% of the samples exceeded the acceptable limits set by World Health Organization Safety guidelines (Food Chemistry 113 (2009) 420–423). We are not saying that these toxins are concentrated in JP because we just don’t know (as these specific studies have not been done). However, JP’s foundation is juice and as such it is at least a reasonable request to look into this issue further before recommending JP to everyone. Especially when healthy whole foods (that don’t raise these same concerns) are readily accessible to most people who are able to buy JP.

In fact, at this point V8 juice is looking as good as JP if measuring how “whole” the product is. However, JP sinks below V8 on the “whole food” scale because of the second step in processing the fruit and vegetable juice into a powder/extract, a form they could put into a capsule. So JP took an already nutrient depleted juice (compared to its whole food counterpart) and processed it into a powder, resulting in even more nutrient loss. As such JP had to then add a list of isolated nutrients back to the JP concoction just so it could have the amounts of nutrients advertised on the labels. In other words, the processed juice of the fruits and vegetables doesn’t provide all of the nutrients listed on the JP label rather that is provided by the added isolated nutrients, which in our opinion is the complete opposite of how JP advertises itself. In fact, JP even admitted that they supplemented their product with isolated nutrients in the past (Samman 133 (11): 3726. (2003)).

Before we go on, here is a list of the ingredients of some of the common JP products, so you can see for yourself exactly what we are going to talk about:

As you can see, JP lists a lot of ingredients that look suspiciously unlike any whole foods we have seen before. Moreover, the names of many of the ingredients are complicated so we took the liberty of explaining what some of this stuff was. Without knowing that information how could we, or anyone else for that matter, make a truly informed decision about whether or not to take the JP product? Let us now go through the list of JP ingredients and carefully examine this product that is being sold to people as a whole food supplement.

First there is the dehydrated juice of the fruits and vegetables that is processed into a powder. We have already discussed that so let’s move on to the next ingredient, which is gelatin (an animal protein). Animal proteins are connected to many problems including osteoporosis, food allergies, gout, and kidney stones to name a few (Am J Clin Nutr 1988;48:837-41; J Allergy Clin Immunol. 2007 Dec;120(6):1399-405. Epub 2007 Nov 1.; N Engl J Med. 2004 Mar 11;350(11):1093-103; J Clin Endocrinol Metab.1988 Jan;66(1):140-6.). We have found that JP is often taken by people who are trying to avoid animal proteins (possibly not realizing they are getting a dose of animal protein with each pill or gummie), so this needs to be made clear, especially in the population likely to purchase JP.

Next, to the dehydrated juice extract wrapped in an animal protein shell, JP then adds plant enzymes. Supplement consumers seem to be attracted to enzymes. This is likely due to their deep-rooted fear that the human body is deficient and that they feel lousy because of elements missing such as enzymes to digest their food. In fact, enzymes are really unnecessary for people (unless a proven enzyme deficiency), and still potentially harmful even if taken for a proven deficiency (N Engl J Med1997;336:1283-9.). What’s more, plant enzymes are particularly useless in humans. Humans make all of the enzymes they need for the specific reactions that go on in their human bodies. Plant enzymes are made for reactions that go on in plants. We don’t require plant enzymes rather we use our own human enzymes to digest our food. However, even if we wanted to acquire our enzymes from an external source (instead of relying on our bodies to make the appropriate types and mounts), we still have the problem that acid deactivates enzymes. And acid is the first obstacle encountered by substances we ingest. So not only are supplemental enzymes unnecessary in most people but they are likely deactivated anyway. Nevertheless, people seem to get excited when they see enzymes in the mix of ingredients. If only these people realized that their stomach issues and other health problems were due to a plant food deficiency rather than a plant enzyme deficiency…life would be much better. Well, until that happens, adding enzymes to supplement products will likely just boost sales.

Going forward in the ingredient list we get to the different fiber supplements that are added back to the pill. This seems a little silly. Why remove all the juice from the original fruits and vegetables (originally full of fiber), leaving the “waste” (which we know based on medical studies was still extremely health promoting), only to add back different fibers (that come from isolated sources such as date fiber, citrus pectin, etc.) rather than just consume the whole food in the first place? This seems like a lot of trouble to go through when you could just simply eat the apple, orange, pineapple, cranberry, peach, acerola cherry, and papaya (whole fruits) and accomplish all of your goals in a much cheaper and safer fashion.

The next ingredients are citrus bioflavonoids, which are types of antioxidants. Again this is an isolated nutrient where they take a citrus fruit and extract the bioflavonoids. For someone to say this is less of an isolated nutrient than beta-carotene supplements doesn’t make much sense. Why would extracting bioflavonoids from a plant be any different than extracting beta-carotene from a plant? Wouldn’t it at least be reasonable to wait and perform good, long-term studies (larger groups of people over 10 years) prior to taking an isolated nutrient like citrus bioflavanoids and especially before recommending that everyone starts consuming these supplements? It seems irresponsible not to wait considering studies already exist showing that taking an isolated nutrient like beta- carotene increases the overall risk of cancer and death (JAMA. 2007;297(8):842-857)?

It is true that increased fruit and vegetable consumption is associated with a decreased incidence of cardiovascular diseases, cancer, and other chronic diseases (Am J Clin Nutr 2002;76:1–2.). However, the beneficial health effects of fruits and vegetables have been attributed, in part, to antioxidant flavonoids present in these foods rather than the whole foods themselves. An interesting article took a look at this phenomenon a little more closely. (Free Radical Biology and Medicine Volume 41, Issue 12, 15 December 2006, pp. 1727-1746) This article said, “ large, transient increases in the total antioxidant capacity of plasma have often been observed after the consumption of flavonoid-rich foods by humans. These observations led to the hypothesis that dietary flavonoids play a significant role as antioxidants in the body, thereby reducing chronic disease risk. This notion, however, has been challenged recently by studies on the bioavailability of flavonoids, which indicate that they reach only very low concentrations in human plasma after the consumption of flavonoid-rich foods. In addition, most flavonoids are extensively metabolized in vivo, which can affect their antioxidant capacity. Furthermore, fruits and vegetables contain many macro- and micronutrients, in addition to flavonoids, that may directly or through their metabolism affect the total antioxidant capacity of plasma.” This article concluded that the antioxidant effects are not due to the flavonoids themselves rather they are due to what happens both directly and indirectly as a result of eating the whole food. This conclusion would make adding bioflavonoids to foods unnecessary and potentially risky (as in the beta carotene example). What’s more, there are over 5000 different naturally occurring bioflavonoids occurring in plants so not only are we getting even more bioflavonoids than those 5000 when we consume whole fruits and vegetables (as we likely we haven’t discovered many that are still being consumed when eating whole foods). Moreover, to pick some and add them into a capsule in an imbalanced and haphazard fashion is potentially dangerous (Biotechnology Journal Volume 2 Issue 10, Pages 1214 – 1234).

As usual we need to stop our reductionist thought process in general, especially when dealing with this new bioflavonoid craze. According to an article that quotes Balz Frei, professor and director of the Linus Pauling Institute (a national leader in the study of such phytochemicals, or a plant chemicals that may affect human health). In an Oregon State University News Media Release he said, “flavonoids are highly metabolized, which alters their chemical structure and diminishes their ability to function as an antioxidant.” He then went on to say, “If you measure the activity of flavonoids in a test tube, they are indeed strong antioxidants. Based on laboratory tests of their ability to scavenge free radicals, it appears they have 3-5 times more antioxidant capacity than vitamins C or E. But with flavonoids in particular, what goes on in a test tube is not what’s happening in the human body. The body sees them as foreign compounds and modifies them for rapid excretion in the urine and bile.” Unfortunately, when looking at real life situations (rather than the test tube in a lab) the 5% of flavonoids actually absorbed is rapidly metabolized and excreted from the body (Free Radical Biology & Medicine, Vol. 36, No. 2, pp. 201 – 211, 2004). In other words, what we think we know is occurring may not actually be happening and our reductionist approach to dealing with this complex system is potentially very dangerous.

Other ingredients in JP include catechins which are antioxidants found in tea. Yes, they have done studies in mice that showed some minimal decrease in accumulation of plaque in arteries when injected with antioxidants like EGCG from green tea extract (Circulation. 2004;109:2448-2453). But this was in very sick mice (because they were genetically altered for research purposes) with total cholesterols over 1000mg/dL (note normal cholesterol in humans is around 150mg/dL). Moreover, the change in plaque size was a mere 15 thousandths of a millimeter (0.015mm), which is very small with an unknown, if any, clinical significance. So this study at best says that maybe in humans, although we don’t know for sure as this was in mice, injecting antioxidants from green tea extract helps decrease plaque build up a very little bit. And despite all of that we still don’t know if that has any effect on our chance of heart attacks or overall death. But on the flip side there are studies that show that green tea extract consumption may cause liver failure in humans (Liver Transplantation 12:1892-1895, 2006). So even if there was some benefit on the blood vessels, we still have to weigh that against risks such as liver failure. With these questions not adequately answered, maybe it is better to drink the green tea from the whole tea leaf rather than consume substances like catechins found in the tea leaf particles or worse, inject the extracts. Especially given the fact that some data actually suggest that the benefit of tea on our blood vessels has nothing to do with catechins and other antioxidants (Free Radical Biology and Medicine Volume 38, Issue 4, 15 February 2005, Pages 499-506 ). Ultimately, we know drinking tea is not only safe but also connected to many healthy benefits, so why not just continue drinking it from the whole tea leaf? Why go out of our way to spend the time and money reducing a healthy product like a tea leaf into an extract to then be consumed, when focusing on this single isolated ingredient could result not only in our missing the part or parts of the tea leaf that are actually promoting health but possibly also cause actual harm?

One of the most common mistakes we make is assuming that if something is healthy in its natural form then to manipulate it (processing it into an extract) or taking tons of it (taking capsules full of the substances) is even better. This is a dangerous assumption as more is not always better. Taking healthy foods and then concentrating them and/or taking them in increased amounts has in fact been shown to be harmful. For example, turmeric is a very healthy spice shown to have anticancer and antimicrobial benefits. In fact, turmeric was found to inhibit cancer cell invasion and possibly be important at preventing cancer metastases (Journal of Nutritional Biochemistry 20 (2009) 87–95) and was even being considered as a leading possible treatment for multi-drug resistance breast cancer (Steroid Enzymes and Cancer: Ann. N.Y. Acad. Sci. 1155: 278–283 (2009). However, when they looked at larger supplement doses of turmeric they actually found that it caused problems such as increased urinary oxalate levels and increased kidney stones (Am J Clin Nutr 2008;87:1262–7). In fact, some studies have shown that curcumin, the active ingredient of the spice turmeric, may produce toxic and carcinogenic effects under specific conditions and may also alter the effectiveness of certain cancer treatments. (Mol. Nutr. Food Res. 2008, 52, S103 – S127). So a little bit of turmeric to season food appears to be perfectly safe and likely health promoting, but when we start manipulating the spice or taking it in larger, supplemental doses we actually can cause harm. Another example has been shown with tea, which has been associated with improved immune system functioning (Nutrition Research 27 (2007) 373–379), cancer prevention (Carcinogenesis vol.28 no.5 pp.1074–1078, 2007) and decreased death from heart disease as well as overall death (JAMA. 2006;296:1255-1265). However, the concentrated extract was actually shown to potentially cause harm including liver failure (Liver Transpl 12:1892-1895, 2006).

Taking certain medications that are potentially harmful is sometimes acceptable in sick patients where the benefit of the treatment outweighs the risk. However, healthy people would not reasonably take that same risk. Why should we assume that taking a concentrated fruit and vegetable extract found in JP wouldn’t cause problems of its own? Why should healthy people consider any risk when the benefits are so unclear? Remember that just because a little of something is healthy doesn’t mean a lot of that something concentrated into a supplement is healthier—or even healthy at all. A reverse example of this can be seen with black pepper. Studies show that giving the human equivalent of ½ cup of black pepper to mice causes a slow agonizing death. However, a little black pepper in human studies was show to have anti-inflammatory, anti-mutagenic, and anti-cancer effects (Critical Reviews in Food Science and Nutrition, 47:735–748 (2007). So not only do we need to focus on human studies when evaluating food and health connections but we also need to focus on using natural amounts that we would get in our diet rather than trying to best nature by increasing our intake through the use of concentrated extracts in the form of supplements.

Next on the JP ingredient list are indole carbionols, which are basically hydrolyzed glucosinolates. Glucosinolates are the substances that researchers feel give the cruciferous vegetable family their potent health benefits. Yes, in a lab certain glucosinolates from broccoli seemed to decrease cancer cell growth but does that mean that these foods are health promoting? Possibly, but not necessarily. An interesting article showed that although isothiocyanates and indoles derived from the hydrolysis of glucosinolates, such as sulforaphane and indole-3-carbinol (I3C), have been implicated in a variety of anticarcinogenic mechanisms. Deleterious effects also have been reported in some experimental protocols, including tumor promotion over prolonged periods of exposure (Pharmacol Res. 2007 Mar;55(3):224-36. Epub 2007 Jan 25.). We are by no means telling people to stop eating greens as whole vegetables. However, we are saying that before isolating nutrients from those greens (such as indole carbinols that are added to JP) and consuming them on a daily basis, more studies clearly need to be done.

Other ingredients in JP include lycopene, which is a bright red carotenoid found in foods like tomatoes and watermelon. It is one of the substances thought to be responsible for certain health promoting effects of foods like tomatoes. But could it be possible that lycopene is just one player in a symphony of nutrients? Isolated lycopene, not the tomato, was found in at least one study, NOT to have any benefit on cancer promotion (American Journal of Epidemiology 2009 169(7):815-828). What’s worse, in that same study a close relative of lycopene, lutein, was found to increase cancer risk when taken in supplement form. Other carotenoid supplements have also been linked to increased cancer risk including beta-carotene (N Engl J Med 1996;334:1150-5. ). Once again, here is another example of how taking these isolated nutrients added to a supplement is potentially dangerous, whereas eating the whole food containing these nutrients (among millions of others) is clearly health promoting.

Equally concerning to us are the mixed tocopherol stabilizers in JP. There are large studies that show that vitamin E supplements increase mortality compared to placebo (JAMA. 2007;297(8):842-857). So then when we noticed mixed tocopherol stabilizers were in the list of ingredients of JP, which is just a fancy way of talking about substances with vitamin E activity or vitamin E, we were even more worried. In other words, for all intents and purposes JP also adds vitamin E to the mix of ingredients and we know vitamin E is harmful.

Next are the JP gummies that are marketed as a healthy snack for children. Not only do they have many of the ingredients just reviewed over the last few pages but the calories come from pure junk. How can anything that is 85% corn syrup be healthy? Then another 10% is pure gelatin (animal protein) and another 3% comes from natural flavors and colors. Interestingly, JP gummies were no different than placebo (a sugar pill) in a study looking at JP gummies effects on markers of oxidative stress in children (J Am Diet Assoc. 2002; 102:1652-1657.) So the data there show that JP gummies were no better than a sugar pill, possibly because JP gummies are 85% sugar (corn syrup). JP does advertise the “Children’s Health Study” stating that when people start taking JP they eat less fast foods and soft drinks or they eat more fruits and vegetables (how much more is not clear). But do we really need to take JP to achieve these results or could we save these people some money and potential harm from supplementation, instead focusing on educating them to simply eat less fast food and more fruits and vegetables?

JP always talks about the data supporting its use. They seem to really push the fact that JP has data to stand behind their recommendations. Yes, it is true that JP has funded studies (which is more than we can say for most supplement companies) and at first we were excited when others (including doctors) would tell us about how great the data were. That was until we looked at all of the data and realized they were not as good as you might think. We often hear that supplements are beneficial when using surrogate markers of improved health such as their effects on cholesterol levels or blood vessel spasms or some other biomarker. It is harder (takes more time and people) to see changes in more important health outcomes such as heart attacks and, at the top of the list of importance, death. But relying solely on biomarkers to support the use of a drug or supplement has caused problems over and over again in the past. Think of this as a progression. The easiest benefit for researchers to show are changes in biomarkers like cholesterol levels, the next level of difficulty would be demonstrating changes in the rates of heart attacks and strokes, and then the final, most difficult (but also most important) difficulty level to reach would be to show changes in the rate of death or mortality rate. Even with death rates, companies sponsoring the studies often break that up in an effort to show benefit of their product in any way possible. For example, a product might show a decrease in risk of death FROM CANCER but not overall death. That is not as important to us. In other words, what if your rate of death goes down from cancer but up from heart disease. Then your overall death rate (which is what you really care about) is actually unchanged even though the study looks impressive for advertising a decrease in the rate of death from cancer. So you have to be astute when analyzing the data and we have found that most people who talk about the “data” often overlook areas of potential concern.

So whenever our patients want to get excited over supplements effects on simple biomarkers like cholesterol levels we remind them of a show called, “Mythbusters” (where they do interesting experiments to dispel popular myths). This one particular episode provides a great analogy to the problems that could occur if researchers don’t push to evaluate the most important (although most time consuming and difficult) outcomes like mortality rate or death. This “Mythbusters” episode was looking at magnets as a possible shark repellant (sharks are known to sense electromagnetic energy). They wanted to know if divers could attach magnets to their wetsuits to repel and then safely swim with sharks. This was obviously something important to test prior to just assuming it worked. So just as there are three basic tiers of difficulty when testing medical interventions, this show went through three tiers. The first test they did was on a small shark that they held in hand and then brought a magnet up to its head. The shark immediately pulled away from the magnet. This happened multiple times so they assumed the magnets were a success. However they didn’t start selling magnets as shark repellents because they weren’t quite sure. Instead they took the study to the next level. They put a medium sized shark in a long tank with a line of magnets going across the tank half way down the underwater track. The shark was then released and, on multiple attempts, continued to turn away rather than cross the line of magnets.

So at this point, after two separate shark trials, it appeared that sharks were in fact repelled by magnets. However, with sharks and divers they couldn’t afford to be wrong. So they took the time and expense of taking the experiment to the an even more difficult tier. After all, they had to be sure the magnets were in fact safe shark repellents. For this test they went out to the ocean with divers, cages, cameras, and even bigger sharks. They then took boxes of dead fish and covered the boxes with magnets to see if hungry sharks in the ocean around divers would still be repelled by magnets, the ultimate test if you will. However, in the real ocean setting the sharks ignored the magnets and went right after the boxes of dead fish, attacking them relentlessly. This illustrates an important point. All a diver really cares about is whether they will be attacked by big sharks in the ocean. The small shark thrashing away from the magnet or the medium shark not crossing a line of magnets may be interesting and promising but does not tell the diver exactly what he/she truly needs to know. Similarly, changes in cholesterol numbers after taking supplements are interesting but doesn’t tell us what we really need to know; rather we need to know if we are going to have heart attacks and/or die. Similar to the shark studies, it would be potentially dangerous to assume that just because a pill lowers cholesterol it improves more important health outcomes like heart attack and death rate.

In fact, just looking at rates of heart attacks is still not enough, as most people wouldn’t care about having less heart attacks as a result of a treatment if they were more likely to die from the treatment. Similarly, if the divers just relied on surrogate markers of whether magnets worked as shark repellents (small shark moving away from the magnet or medium shark not crossing a line of magnets in a long tank) they would have come to an incorrect conclusion that magnets are good shark repellents in the ocean, and the divers very likely would have gotten hurt or even died. All we are trying to do is avoid the same issue with supplements or any other intervention where surrogate markers alone are used to recommend a treatment. Just as in the show “Mythbusters,” where they waited until a good study was done on the exact outcome they care about (divers swimming in the ocean with big sharks), we too recommend waiting before taking supplements.

Only when those good studies are done can we be sure that our conclusions of benefit without harm are correct. Who knows why the sharks were first repelled, maybe the magnetic forces felt uncomfortable, as sharks are known to have electromagnetic sensors. But when the situation was more like real life, with hungry sharks not confined to cages, the results were quite different. Similarly, when they do studies with supplements such as vitamin A, beta carotene, vitamin E, folate, iron, etc. and see that there are actually increased rates of cancer and death (despite improvements in blood levels of the nutrients or other biomarkers) the conclusions of whether to use these supplements is then different (see references earlier in the paper). So if your goal is to repel a little shark thrashing in a little tank or to simply change your blood levels of a certain vitamin, then that is one thing but if you are concerned about the bigger picture such as a supplement’s effect on overall death, similar to diving in the ocean and getting eaten by a shark, then you should be compelled (as are we) not to make any conclusions until the bigger, longer, more thorough studies are done.

Technology has done many great things for society but with those benefits also come problems. For example, our ability to measure biomarkers is potentially hurting our health when used as the final decision of whether or not to use a product. We are incorrectly assuming that something is healthy (because it affects biomarkers like cholesterol or homocysteine levels in our blood) rather than actually proving that something is healthy. For example, 200 years ago, because they didn’t have the technology to do otherwise, when testing if a treatment prevented scurvy they had to go out to sea and see if the treatment actually prevented scurvy. They couldn’t be lazy and rely simply on biomarkers. In fact, they did learn that lemons prevented scurvy by testing this at sea but they then ran into another problem, moldy lemons. Even then scientists implemented their reductionist theory hypothesizing that the acid in the lemons was responsible for preventing scurvy. As such, doctors gave sailors diluted sulfuric acid as an antiscorbutic (scurvy prevention). But people still got scurvy not to mention sick from the acid (J. Nutr. 133: 638–645, 2003). In other words, they proved that the proposed treatment was unhelpful by taking them out to sea and looking at an outcome measure that they actually cared about. Then they tried lemon juice reductions into syrups (a way to preserve the lemons) but those too did not prevent scurvy when tested at sea (J. Nutr. 133: 638–645, 2003). In other words, the whole lemons worked but the processed foods and reductionist approaches to other treatments did not. Does JP prevent scurvy? Are you willing to go out to sea with only JP or would you prefer to see a good test first. The truth is that, if given the option, I am not willing to bet my life on it without a good test first and I hope my patients don’t either. The point is exactly that, we just don’t know until we really test it. That is what we need to do with JP (or any other intervention) to know if, for example, it prevents scurvy. We need to take JP and see if people at sea develop it, NOT look at JP’s effect on some biomarker. Unfortunately, our ability to use a biomarker in the present day and age replaces our need and desire to do the bigger and more important tests like testing JP at sea.

When reviewing the data with JP the studies show beneficial effects on surrogate markers like homocysteine and cholesterol, which, even if the studies were flawless, are not enough to recommend usage. However, just to demonstrate how studies need to be carefully analyzed to get the true conclusions we are going to review one of the more popular JP studies on Flow Mediated Dilatation (FMD). We picked FMD because it is not just a blood level of some biochemical marker, rather it is at least an effect in the body, and as such may possibly serve as a better indicator of improved health (at least compared to relying on certain blood levels of biomarkers like cholesterol and homocysteine). We picked this FMD study because its conclusion was very favorable towards JP implying that there was about a 30% reduction in the detrimental effects of high fat meals on the blood vessel (JP protected the vessels from the detrimental effects of high fat meals) compared to no beneficial effect from placebo. Just to clarify, when blood flow increases through a vessel, the vessel dilates. This phenomenon has been coined flow-mediated dilatation (FMD). High fat meals seem to impair this function preventing blood vessels from dilating appropriately. Note how FMD is still a surrogate marker of improved health because people don’t care as much about whether their blood vessel constricts after a fatty meal rather they care about having a heart attack or dying. More importantly, we would want to know that even if a product prevented blood vessel constriction (potentially a good thing) it didn’t also do something harmful, such as increase heart attacks or death (clearly a bad thing). The good news is that this study did not show an increase in heart attacks or death, but the bad news is that is also did not look for an increase in heart attacks of death.

In this study, researchers looked at JP and JP + another antioxidant/herbal supplement called Vineyard (V) and compared them both to placebo (J. Am. Coll. Cardiol. 2003;41;1744-1749). In this study researchers looked at different outcomes in the three groups including cholesterol levels and flow-mediated dilatation (FMD). Interestingly, they induced blood vessel spasm by feeding the test subjects an Egg McMuffin, Sausage McMuffin, two hash brown patties (McDonald’s Corporation), and a non-caffeinated beverage. This meal, despite being 50% fat, was deficient in the essential omega 3 fats (a fat known to be essential for optimal heart and blood vessel functioning) and deficient in many essential vitamins, minerals, and fiber. Anyway, researchers measured what percentage a particular blood vessel dilated (during increased blood flow hence the term Flow Mediated Dilation or FMD) when fasting compared to 3 hours after that high fat McDonald’s meal. It is important to understand that the amount that a blood vessel dilates (FMD) is impaired by a high fat meal but not completely blocked by a high fat meal. As a result the blood vessel still dilates even 3 hours after a high fat meal; however, it dilates by a smaller amount or percentage. For example, you can see in the table below that at baseline in the placebo group the blood vessel dilated by 20.2% when fasting but only by 11.7% 3 hours after a high fat meal (the high fat meal impaired the vessel from fully dilating). So researchers would then summarize that result as an 8.5% absolute reduction in FMD (20.2%-11.7%=8.5%), thought to be due to the high fat meal. What they then attempted to show was that by taking JP for 4 weeks people could prevent a reduction in FMD that typically resulted from a high fat meal, and in a way they were successful. See the chart below for the results (3 hours after a high fat meal):

% of Increase in Blood Vessel Dilation (FMD) Before!

PLACEBO

JP

JP + V

Baseline

20.2 → 11.7

13.2 → 7.63

15.8 → 8.0

After 3 weeks

15.7 → 9.9

9.4 → 6.4*

15.8 → 12.4*

After 4 weeks

15.3 → 10.2

9.7 → 7.4*

12.8 → 11.2*

*not a statistically significant difference

The results did show that after 4 weeks of taking either placebo, JP or JP+V that the JP and JP+V groups did not have a statistically significant decrease in blood vessel dilation (FMD) after eating the fatty meals (so those numbers are considered equal), whereas the placebo group did have a statistically significant decrease in blood vessel dilation after eating the high fat meal (remember that decrease in blood vessel dilation or FMD is considered bad and that no decrease in dilation is a good thing). However, using the difference in percentage of dilation is a tricky outcome measure to use. Saying there is no difference in dilation is different than saying there is no decrease. For example, if the blood vessel dilates 13.2% when fasting and then after a high fat meal dilates by only 7.63%, then that decrease in dilation is considered an unhealthy thing (diseased blood vessels don’t dilate properly). However, after one month the article states that, by taking JP, the test subjects did not have a decrease in dilation thanks to the JP. Interestingly, the JP group’s blood vessel dilation, after 4 weeks on JP, now went from 9.7% to 7.4% (not statistically different). It is important to note that the difference was not because they started off with 13.2% dilation fasting and stayed around 13.2% even after the high fat meal (which would have indicated true protection from the detrimental effects of a high fat meal), rather it appears that they started off with a SMALLER percentage of dilation to begin with and the high fat meal simply didn’t make it even smaller.

Before taking JP the blood vessel dilation went from 13.2% down to 7.63% and after taking JP the blood vessel dilation went from 9.7% down to 7.4%. In other words, prior to using JP the vessel could only dilate to 7.63% after a high fat meal but after being on JP for 4 weeks the vessel could now only dilate to 7.4% after a high fat meal. After 4 weeks of JP the percentage of increase/dilation was 9.7% instead compared to what it was before starting JP at 13.2%. In other words, taking JP for 4 weeks seemed to possibly impair fasting FMD (13.2% before taking JP and only 9.7% after taking JP). Once at 9.7% (while taking JP for 4 weeks), it would be more accurate to say that high fat meals didn’t impair the blood vessels any further.

This is an important concept so let’s use an analogy to drive it home. Imagine that appropriate dilation in a healthy person would bring their blood vessels to the size of a basketball. Now after eating a fatty meal, which impairs dilation, let’s say their blood vessels could only dilate to the size of a tennis ball. Then let’s take someone who is sick and has artery disease who at baseline can only dilate their blood vessels to the size of a tennis ball. After their fatty meal, which impairs dilation, they can then only dilate their diseased blood vessels to the size of a gold ball. If you focus only on change in artery dilation, you might conclude inappropriately that the smaller decrease is better. But that is only if both groups start out with a basketball size artery (then whoever has the smallest change is in fact the healthiest). If the sick person with the diseased arteries starts off with a tennis ball (a sign of disease NOT health) and then only decreases a little more to the size of a golf ball, then that is still not good. The point is that before we make any conclusions, we should at least start from a level playing field (all basketballs). If JP wants to make the claim that they have any true effect on FMD, we want to see studies comparing basketballs to basketballs and not basketballs to tennis balls.

What’s more, even the placebo group’s blood vessel fasting percentage of dilation was 25% lower after 4 weeks on placebo (15.3% instead of 20.2%), which trended towards but did not achieve statistical significance. Nevertheless, why are these numbers so variable? And seeing as how variable these numbers are, how much can we really conclude from these results? A bigger study is clearly needed to really interpret anything from these results.

Another problem is that when studies are small, they do not help us determine what to do with large groups of people. There were only 38 people total that were supposedly evenly distributed. However, the results were written up with 10 people in the placebo group, 14 people in the JP group, and 12 people in the JP+V group. What’s more, the chart talks about the analysis of “38 normal subjects” but those numbers only add up to 36. Did they remove two people? Would the results have been different if those two people were included? Moreover, why did they design the study to not place equal weight in the placebo group? They made the placebo group have less people which clearly could have skewed the results in such a small study overall. They also didn’t include data to calculate if there were any difference between the placebo group and the JP and JP+V groups at baseline. The differences for the 3 groups (between fasting and eating the fatty meal) may have been similar at baseline but why did the placebo group have a much larger percentage of vessel dilation compared to the JP group at baseline (20.2mm vs. 13.2mm) when fasting? Was one group sicker or different in some other way than the other groups at baseline? Usually this problem is avoided when the groups are randomized. However, these groups were so small that they still should have evaluated this issue, as it clearly could have skewed the results.

The funniest part of this study is that they are going out of their way to recommend JP based on what happened in 36 unevenly distributed people. Moreover, why not focus on what seems to be causing the blood vessel dysfunction in the first place, the McDonalds meals! We already know studies show that oil/high fat meals impair blood vessel dilation so why not change the meal rather than add JP (J Am Coll Cardiol. 2000;36: 1455–60)? And if the JP distributors are going to extrapolate even further and recommend JP to people already on a healthy low fat diet, shouldn’t they first see if there is any difference in FMD by doing a study where they feed the test subjects a healthy, oil-free, whole foods, plant based diet? Well, that study would likely be unnecessary because you cannot show a benefit of a pill like JP if there is no problem to fix in the first place. In other words, JP is showing that it can help something that needs not ever be an issue. It is similar to trying to find a cure that prevents someone from hitting himself or herself in the face…probably not the best place to focus our efforts if you ask us.

Another interesting point is that JP+V (the group with the extra antioxidants) actually had a greater effect on FMD than JP alone, BUT JP-V had no effect on cholesterol. So which surrogate marker is more important? We can’t just pick and choose surrogate markers depending on which one helps prove our point. If something is good for us it should improve our health all around and as such should improve ALL surrogate markers we are using to equate to health, not be variable. This variability makes an even stronger argument that we should wait until tests on mortality and other hard morbidity outcomes (like effect on heart attack rate) are done. And even if you wanted to take the leap and say JP has a benefit then the most you could argue is that there is a benefit in those eating one of the unhealthiest meals imaginable: a sausage McMuffin, egg McMuffin, and two hash browns.

It is clear that JP has never been shown to improve any important health outcome such as decreasing heart attacks, decreasing death, etc. It has been shown to improve certain biomarkers such as cholesterol levels, flow mediated dilatation, homocysteine, etc. But we get into trouble when we reduce health and disease to these biomarkers like homocysteine. Studies in the past have shown that people with high levels of homocysteine had higher rates of heart disease as well shown that folic acid has been found to significantly lower homocysteine levels in the blood. As a result, experts thought folic acid would be a highly effective supplement to improve health. But the truth is that people who eat lots of fruits, vegetables, and whole grains all have lower homocysteine levels because of many reasons (low methionine intake from decreased animal protein consumption, folate naturally found in plant foods, etc.). More importantly, because of the increased plant and decreased animal intake, these people have a lower risk of heart attacks in general (Circulation. 2008;118:1929-1937.). And the lower homocysteine level is likely just a marker of a healthy diet not the cause of good health. This is the same as high levels of bioflavonoids being a marker of high fruit and vegetable intakes and not necessarily the cause of good health.

It is short sighted to think that evil homocysteine is the only problem (just as it is short sighted to assume that the bioflavonoids are the cause of improved health). This issue with homocysteine is supported by the many studies that looked at folic acid singled out and supplemented as a pill to lower homocysteine levels (which it does rather effectively). Unfortunately, despite folic acid lowering homocysteine levels, brachial artery vasodilatation or carotid artery stiffness does not change (Arterioscler. Thromb. Vasc. Biol. 2001;21;2072-2079) implying that our bigger concern, the health of our blood vessels, was not addressed by this artificial lowering of the homocysteine levels. In fact, studies showed that folic acid supplementation actually caused more cancer, heart attacks, strokes, and deaths (BMJ, Volume 329, December 2004. & N Engl J Med 2006;354:1578-88 & Am J Clin Nutr 2003;77:221–5). In other words, if we are going to use surrogate markers as an indicator of the more important outcomes such as heart attacks and death, then we need those surrogate markers to actually extrapolate to true health outcomes that we care about (heart attack, stroke, and death rates) as well as be consistent across the board, for example, FMD and cholesterol both improve accordingly.

Unfortunately, when using different surrogate markers we have problems with inconsistency and as such get confused. In this JP study that looked at FMD (J. Am. Coll. Cardiol. 2003;41;1744-1749) they also looked at cholesterol. They found that JP+V improved FMD the best but then JP+V had no effect on cholesterol. So how do we know which surrogate markers are right? We also know that vitamin E has similar beneficial and protective effects on FMD as did JP (JAMA. 1997;278:1682-1686), but then vitamin E also increases cancer and overall mortality (JAMA. 2007;297(8):842-857). So isn’t it reasonable to think that if JP has similar effects as vitamin E on FMD, and vitamin E increases risk of cancer and overall mortality, then we should at the very least do a similarly large trial with JP to prove that JP does not also increase cancer and overall mortality or cause other problems?

Both scientists and physicians understand the problems we have run into in the past when we focused on surrogate markers like cholesterol levels in the blood instead of hard outcomes like heart attacks and, more importantly, death or mortality. For example, there was a drug called clofibrate, which was great at lowering cholesterol and even decreasing heart disease but when adequately studied was also shown to increase mortality compared to placebo (Bulletin of the World Health Organization, 57(5)801-805, 1979; Lancet, 1984 Sep 15;2(8403):600-4). Similarly, we need to wait until studies on JP are done on large groups not 10-12 people in one test arm.

To make matters worse, supplements are not controlled by the FDA. The FDA is good (better than nothing) about following up drugs once they are released, to collect the adverse events and even pull medications off the market if needed. We all know the FDA could do a better job of protecting public health and that there are serious conflicts of interest between the FDA and the pharmaceutical companies but that issue is the focus of an entirely different essay. That all being said, the FDA still comes through from time to time. For example, Baycol, a cholesterol medication, was linked to severe muscle breakdown and kidney damage and as a result was taken off the market. Who is going to oversee products like JP? If someone comes to the hospital with a heart attack, kidney failure, or other medical problem there are so many other variables present that no one would even notice if JP was responsible for increasing the risk of that particular event. That is why JP (and any pill for that matter) needs to be studied first. We have heard people say that if there were problems with JP they would have come out by now. But that is not only unscientific but ridiculous because there is no way to know this without a good study. We want to, at the very least, be sure that JP doesn’t increase heart attacks, cancer, deaths, etc., (as other supplements have been shown to do). Moreover, even if it turns out to be safe we would need a good reason to recommend JP on top of a diet already rich in whole fruits and vegetables and low in fat.

Unfortunately, most people don’t even care about all of these issues concerning the data. They are more excited by the testimonials and JP is excellent about advertising those. We think testimonials are great but they simply aren’t evidence. But whether intended or not, people take supplements like JP because doctors or other “experts” convince them in some way this is a good and necessary product, often with anecdotal rather than scientific data. Patients in good faith take JP and then, whether a placebo effect or not, may feel better. Next they tell others the product they are taking is the reason they are feeling better (along with the misunderstanding that JP = vegetables) and recommend JP to others. This process repeats over and over again. The problem is that this is all very misleading and our job as patient advocates is to explain this to our patients and protect them from misinformation. We all want our patients to feel better and as such we wouldn’t take their precious supplements away, rather we would explain our concerns and better inform them. After that the decision is up to them. However, most patients, once well informed would rather spend $600 a year on something other than JP, especially once they understand that there is no proven benefit on actual health outcomes they care about (heart attacks and death) and potential harm compared to a placebo pill. Not to mention they can get many more times the antioxidants along with all of the other nutrients by simply eating an apple. Now we may be wrong, as there might be some people who would continue taking JP even once well informed. But then that is based on their, now well-informed, decision…not misinformation. How many people out there are really well informed? Heck, it took us quite a while to get all of this information together and we are trained at doing this. So our guess is that most people taking JP right now have only part of the story and even less of an understanding about the problems with supplements and the processing of whole foods.

As an aside there is an interesting case to illustrate why we can’t depend simply on testimonials (someone taking a pill and then saying how great they feel). In other words, the importance of differing between placebo and drug effects. We will use a study that looked at people who suffered from restless leg syndrome RLS (a particularly uncomfortable medical problem). People would do just about anything including spending hundreds of dollars on drugs to treat this problem. For example, the drug Requip was studied to see how well it treated RLS. They found that 70% of people taking the pill reported improved symptoms of RLS. So out of 100 people given Requip, 70 said it was a fantastic pill as it reduced their symptoms. That alone makes the drug look amazing to anyone listening. And if allowed to stop there then all drug manufacturers would be very happy to get results like that to publish and advertise. However, the FDA tries to protect consumers of medications by mandating a placebo-controlled study prior to approval of any medical treatment. Why you might ask? Because, without a placebo arm consumers are misled by inflated benefits attributable to the drug. Interestingly, in this study with Requip, 55% of those taking placebo also said their symptoms improved, as they were unknowingly taking a placebo (Mayo Clin Proc. 2006;81(1):17-27). So if we just used testimonials taking Requip (not controlled with a placebo) we get a significantly and inaccurately inflated idea of how beneficial the actual drug is. As such we would inaccurately conclude there was a 70% improvement in symptoms due to the drug (if not studied against a placebo in a controlled setting) instead of the more accurate figure 15% (70% – 55% = 15%) attributable to the drug. And what patients really want to know is how beneficial the drug itself is to determine if it is worth the expense and risk of taking it. If they equate testimonials to that number then it is our job, as patient advocates, to explain that that is only half the picture, especially before they spend the money and endure the side effects of the treatment. Noting that Requip caused 15% less restless leg symptoms, decide for yourself if that is worth it once your learn that Requip also caused 35% more nausea, 7% more vomiting, 7% more dizziness, and 11% more somnolence/fatigue compared to placebo. So yes testimonials are great and we love when people are happy and feel better for any reason, but we need to keep that separate from our decision making tree about recommending a treatment or not.

One of the main problems with JP is that it preys on people who incorrectly assume that because the American diet is so unhealthy some supplementation could only help. But that is not what the science says. Supplements have been shown not only to be no better than placebo but actually to cause harm in many cases (see references above). And that is based on studies in the average American (who is on a diet devoid of many nutrients). In other words, even when on a nutrient poor American diet (which is different than someone proving they have a particular nutrient deficiency in their body), adding isolated nutrients is not only unhelpful but also potentially harmful. The funny thing is that the people most likely to supplement are usually those that follow a healthier diet. And even if we want to provide patients with a placebo effect, which is not necessarily a problem in and of itself, then we must do so without causing harm. Our concern with a supplement like JP is not that it may just be providing a placebo effect (although this is still misleading in our opinion) rather that it has not been studied for long periods of time in large groups of people looking at morbidity and mortality outcomes. And until that is done we don’t know if it is necessary or even safe. That is why our default recommendation, even in the average American on a nutrient poor diet, should be no isolated, processed nutrients. In our opinion if people are willing to spend $600 on JP then they would likely be willing to eat an apple, which is not only safe and affordable but studies have shown that just one apple per day lowers risk of cancer of the oral cavity, larynx, breast, colon, kidney, and ovary (Planta Med 2008; 74: 1608– 1624). JP has not been shown to do this. Ultimately, as a patient advocate, we just want to make sure that our patients are first and foremost SAFE as well as understand the evidence enough to make a truly well informed decision…that works best for him/her.

JP is clearly misleading, as the benefits of fruits and veggies are comprehensive due to getting the daily calories from plants (which are full of fiber, vitamins, minerals, and phytochemicals) while also not eating animal foods which among other things contain toxic levels of protein, fat, cholesterol, and environmental contaminants. JP only focuses on one theoretical problem, a perceived deficiency based on the rudimentary DRI, and clearly doesn’t address any of these other likely much more, important nutrition and health issues. Even worse, people don’t know about these other more important issues and think they are not only safe but also benefit from adding JP to their daily routines. This is similar to patients given cholesterol or blood pressure pills. There are many people out there with high blood pressure or high cholesterol, due to the unhealthy American diet, that think that adding these pills will make them healthy again. Even worse, they continue the same disease promoting diet and lifestyle without a second thought. Normal numbers or biomarkers do not equal normal health and in fact, this mentality misses the big picture (Cardiovascular Drugs and Therapy 2000;14:367-372). Patients don’t realize they have been duped until they get to the hospital with their heart attack (if lucky enough as the most common symptom of a heart attack is dropping dead) despite taking their pills as directed.

The manipulation of vegetable juices into capsule form with the addition of enzymes and isolated nutrients requires too great of a stretch of the imagination to be considered as something “whole food” of any kind. The claim that JP promotes better health is based on poor science, which may deceive people into consuming a product that is potentially harmful. Claims like those made by the JP product manufacturers make our job more difficult as we have to dissuade our patients from the “health in a bottle” mindset—and toward the everyday food choices that can bring about the significant, long-lasting health results they are looking for.

JP raises another issue, the issue surrounding biased recommendations. In our opinion it is wrong for physicians to make money from recommending pills, even if they believe in the treatment. Most reasonable people agree that doctors should not make money by selling cholesterol pills to patients. The same should hold true for supplements. If a healthcare practitioner believes the supplement is beneficial, then it is OK to recommend it. However, the only way a patient can trust that the doctor has no ulterior motives is for there to be no opportunity. In other words, the physician can’t benefit in any other way when he/she makes a recommendation to a patient other than providing accurate advice and simply helping the patient. If the physician makes money then all bets are off. We are not saying that all physicians that sell supplements are taking advantage of their patients in an attempt to make a profit but if there is even the possibility of this occurring then that dynamic needs to be adjusted. Whether we like it or not, our prescribing habits as health practitioners change when there is any outside influence/incentive in any way (Annals of Family Medicine Vol. 3, No. 1 January/February 2005). Because of this dynamic, this should be a universal rule so that patients can unconditionally trust their physician’s recommendations.

To clarify, there is a difference between recommending an inadequately tested product to healthy people and using one as a trial treatment in someone who is sick. For example, if we had a patient who was suffering from an illness such as inflammatory bowel disease despite complying with all of our diet and lifestyle changes, and a colleague said that JP has cleared this up in some of their patients, then we might embark on a JP trial (based on expert testimony), as a treatment for that particular patient in that particular extenuating circumstance. But blanket recommendations to add supplements are a problem even in the average American on the nutrient poor standard American diet. Even worse, imagine some person with cancer who didn’t know that there were studies showing data that the consumption of certain isolated nutrients actually increased cancer risk or that there was the possibility of tumor promotion with certain isolated nutrients not adequately studied yet. Instead he/she was under the false impression that adding something like JP (clearly a manipulated form of nutrients) would help…a far stretch from the facts we currently have.

Ultimately, there are a lot of questions and not enough answers when it comes to JP. Maybe those taking JP now will have guessed right and after some good, long-term studies have data that show that JP improves health by preventing heart attacks or, even better, making us live longer despite an already healthy diet. But maybe those promoting JP now will be wrong and the studies will show increased problems like heart attacks or death. With all of the other supplements healthcare practitioners, albeit initially excited and well intentioned, guessed wrong and as such caused problems as significant as increased death! All we are asking is for people to wait for those studies to happen with JP and not be in such a rush to repeat the same mistakes over and over again. In the meantime let’s focus on what we know provides all of the nutrients we need in the perfect balance tested over billions of years of evolution and as such promotes excellent health – a low fat, oil free, whole foods, plant-based diet.

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